Practice management software

1
Introduction

• Dental records consist of documents related to
  the history of present illness, clinical
  examination, diagnosis, treatment done, and the
  prognosis. A thorough knowledge of dental records
  is essential for the practicing dentist, as it
  not only has a forensic application, but also a
  legal implication with respect to insurance and
  consumerism. This article reviews the importance
  of dental records in forensics.

2
Patient Record

• Within the written notes the following are
  examples of what is typically included in the
  dental record
• Identification data name, date of birth, phone
  numbers, and emergency contact information.
• Dental history
• Clinical examination to include an accurate
  charting
• Diagnosis
• Treatment plan
• Documentation of informed consent
• Medical history a thorough investigation

3
Maintenance of dental records

• Many dental clinics use the traditional paper
  charts the traditional filing systems are
  labeled with the following information,
• Patients surname
• Patients first name
• Patients middle name
• Patients degree or seniority 

4
Record Management

• The recording of accurate patient information is
  essential to dentistry. The dental record, also
  referred to as the patient chart, is the official
  office document that records all diagnostic
  information, clinical notes, treatment given, and
  patient-related communications that occur in the
  dental office, including instructions for home
  care and consent to treatment. Protecting health
  information and diligent and complete record
  keeping is extremely important for many reasons,

5
Retention and storage

• This is often impossible due to space constraints
  and so the advice given by defense organization
  is as follows,
• Treatment Records, X-rays, Study Models, and
  Correspondence is to be retained for 11 years
  after the completion of treatment
• For children, retention of records until the
  patient is 25 years old
• Orthodontic Models retain the original pre- and
  post-operative models permanently, discard any
  intermediates after a period of five years.

6
Confidentiality

• There are certain circumstances when information
  can be disclosed and they include,
• Sharing of relevant information with other
  healthcare professionals involved in a patients
  treatment
• Information may be passed to a third part if the
  patient or legal adviser gives written consent,
  for example, an insurance company
• Where information is requested about a deceased
  patient and consent of the estate or relative is
  sought and there is an investigation of sudden,
  suspicious or unexplained death
• Information is required in the preparation of
  legal reports containing only relevant dental
  treatments
• Access to dental records by the police. Search
  and seizure warrants may not include dental
  records, and therefore should be carefully
  checked
• Clinical research protocols and peer review
  procedures. The name of the patient must be kept
  confidential. If information is to be used for
  teaching purposes then the patients consent must
  be obtained

7

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8
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9

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